Tampa General Hospital

[Pages:40]Tampa General Hospital

In accordance with Tampa General Hospital policy (HR-38), and current Joint Commission guidelines, individuals requesting authorization to perform any functions related to patient care at TGH are required to complete an authorization application with the following supporting documentation, and must comply with the Tampa General Hospital Code of Conduct. This authorization gives Tampa General Hospital the authority to obtain certain information about you and/or release certain information to your employer upon its/their request.

Documentation that must be submitted with this packet includes:

? Completed application and acknowledgement forms ? Resume/CV ? Copy of valid Driver's License ? Copy of valid license and/or certification (if applicable) ? Proof of health/drug screen (you must call to schedule) ? Proof of Human Subjects Education (if applicable) ? Proof of TGH online hospital orientation ? Proof of Liability Insurance (Licensed personnel only) ? Reference letters (3) - Must be in sealed envelopes ? Supervising PhysicianlTGH Supervisor Statement

Please note that completed forms must be submitted to Human Resources, 2nd Floor, East Pavilion. The authorization process includes a review of these forms, a background check and drug screening.

Final authorization approval will be granted by the Human Resources Authorization Committee (HRAC) for non-nursing personnel, and by the Professional Nursing Credentialing and Authorizing Committee (PNCAC) for nursing personnel. Approval is conditional upon satisfactory completion of the authorization process. A TGH badge will be issued upon receipt and approval of all documentation. Badges must be worn at all times while on hospital premises.

Tampa General Hospital

APPLICATION FOR NON-EMPLOYEE AUTHORIZATION

To assure compliance with current Joint Commission guidelines, please complete all of the information below, and return this application to Human Resources for processing and approval.

PERSONAL INFORMA TION

Prefix (Mr.lMrs.lOr.):

Name: -------------------------------------------

(First)

(MI)

(Last)

Suffix (Jr.lSr.lIV):

Address 1:

Address 2:

City:

State:

Zip:

_

Gender: --Social Security Number:

OOB: -------_

Primary E-Mail Address:

_

Home phone:

___

Cell phone:

_

Tampa General Hospital

PROFESSIONAL INFORMATION

Affiliation: (Name of

e-m-p-lo-ye-r-o-r-g-ro-u-p-. -In-c-lu-d-e-d-e-pa-r-tm-e-n-t -n-a-m-e-, -if -ap-p-li-ca-b-le-.)-------

Address 1: ---------------------------------------

Address 2: ------------------------------------

City:

State:

Zip:

_

Work phone:

_

Current Title: ---------------

Length of time in current position:

_

Please indicate your credentials:

RN

AS/AA

BSN

CCRC

BS/BA

_ other (please specify):

_

Please list the Supervising Licensed Independent Practitioner (LlP)ITGH Department Director that you intend to work under:

Please indicate the types of duties that you expect to be involved in:

Chart Review

Clinical Research

Observational

_Rounding

_ Other (please specify):

__

Tampa General Hospital

I understand that my involvement with patient care at TGH is a privilege that is to be conducted under the ethical principles of respect for all persons, beneficence, and justice. I am committed to protecting the privacy of patient health information and abiding by the TGH Code of Conduct during any patient care duties that I am responsible for, and I am committed to minimizing risk for any patients that I care for. I am also authorizing TGH to conduct a background screening which includes a criminal background check and drug screening.

Furthermore, I understand, agree and consent that the results of such criminal background check, and/or positive drug screen may be released to my Supervising Licensed Independent Practitioner (i.e., my employer), and/or TGH Department Director and TGH's Human Resources personnel who need to know with or without my knowledge at the time and/or separate prior consent. This signed consent is sufficient and constitutes my full consent and authority allowing Tampa General Hospital the right to provide the results of any background screening and/or drug test to the individuals identified herein including my direct employer if a request by that employer is made. In accordance with the Tampa General Hospital Drug Free Workplace Policy (#HR-BO), I further understand that all prospective employees, travel nurses, employees and other designated persons will be required to submit to a urine drug screen prior to starting work. Persons with a positive pre-placement drug screen, as determined by the Medical Review Officer, will be ineligible to reapply for one year from the date of the positive drug screen.

I also understand that as a Research Associate or Research RN, I will be required to maintain four (4) units of continuing research education annually through the TGH Office of Clinical Research.

I have read and understand all of the statements outlined above.

Name (please print)

Applicant Signature

Date

Tampa General Hospital Release Form Instructions

1. Go to https:/Iweborder.lRelease/release1.aspx?clno=9118 Or go to .and select "Release Form" link on the right-hand side near the top of the screen. Enter 9118 as the 4-digit code.

2. Fill out the entire form, entering as much information as possible.

3. Provide your signature on page 6 of the release form, by using your computer mouse to sign your name.

4. If you make a mistake while signing your name and would like to sign again before submitting, click on the ~ icon to erase and start over.

5. Once you are satisfied with your signature, mark the box below that confirms that you have read and understood the Terms of Service.

1-1TImma, 6. Finally, click

to finish and submit the release.

Tips for optimum use of the online release: ? Use a supported browser, as listed above ? Install Adobe Flash Player, if needed: ? Complete each page/form in less than 30 minutes to avoid session timeout ? If you wish to view a copy of your release form, you will need Adobe Reader. You can obtain it here, if needed:

For questions or problems regarding the online release form, please email info@.

Para informacion en espanol, visite WH'IV.lleaI'1111l0re0 escribe a/a Consumer Fin an cia/ Protection Bureau, 1700 G Street N. W., Washington, DC 20006.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to leammore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

? You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.

? You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

? a person has taken adverse action against you because of information in your credit report; ? you are the victim of identify theft and place a fraud alert in your file; ? your file contains inaccurate information as a result of fraud; ? you are on public assistance; ? you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See conslltncrf'learnmorc for additional information .

? You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

? You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See collsull1crf'learnmore for an explanation of dispute procedures.

? Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed

or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

? Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

? Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need - usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

? You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to \Vww.icammore.

? You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5678688.

? You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

? Identity theft victims and active duty military personnel have additional rights. For more information, visit WWW.learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more iuformation, contact your state or local cousumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS: 1.a. Banks, savings associations, and credit unions with total assets of over S10 billion and their affiliates.

b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau:

CONTACT: a. Bureau of Consumer Financial Protection 1700 G Street tfW Washington, DC 20006

b. Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 (877) 382-4357

2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks

a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions

3. Air carriers

4. Creditors Subject to Surface Transportation Board

5. Creditors Subject to Packers and Stockyards Act

b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480

c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106

d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314 Asst. General Counsel for Aviation Enforcement & Proceedings Department of Transportation 400 Seventh Street SW Washington, DC 20590 Office of Proceedings, Surface Transportation Board Department of Transportation 1925 K Street tfW Washington, DC 20423

Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies

7. Brokers and Dealers

8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations 9. Retailers, Finance Companies, and All Other Creditors Not Listed Above

Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8th Floor Washington, DC 20416

Securities and Exchange Commission 100 F St NE Washington, DC 20549

Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090

FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 (877) 382-4357

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